an image of a baby lying on the bed while a mom holds them

Phase 1: Casting/Tenotomy


Casting

The initial part of the Ponseti method begins with weekly castings that are meant to gently manipulate the feet into the correct position. The early stages of treatment are part of a process that requires commitment by both families and your Orthopaedic Care Support Team. This will help to achieve and maintain optimum results.


What to expect during casting:

  • Gentle manipulation is used to align the foot in a normal position with weekly casting to allow the soft bones to set. Here, the ligaments and tendons are gently stretched.
  • Two team members will apply the cast: one will manipulate the foot and the other will apply the cast.
  • Only the affected foot is stretched and casted. Bilateral cases will have both feet casted at the same appointment.
  • The cast extends from groin to toe.
  • Casting is typically completed within 4-8 weeks.
  • Typically, treatment begins during the first few weeks of a baby being born. This is a time to take advantage of the tissues that have more elasticity.
  • If babies are unable to be casted shortly after birth (coexisting conditions that require first attention, adoption delays, etc.) the Ponseti method has been shown to also be effective with older children as well.
  • Parents are present at this time.
  • This may be slightly uncomfortable for the baby, but the baby is not in pain.
  • At the weekly appointment, the old cast will be removed and the new one applied.
  • Plaster casts are the best material for making Ponseti casts. Some doctors will use soft-roll fiberglass, but we do not suggest this as it is more difficult to feel the positioning of the foot during the application process.
  • It is important to not remove the cast until you arrive at your appointment, as some regression may take place.

What to bring to the appointment:

Supplies for breastfeeding or bottle feeding

A pacifier or comfort object

You can ask about using sugar water on a binky to help soothe the baby

Bath supplies like a washcloth are helpful for cleaning between casts

Spare clothes in case plaster gets on original ones

Improper Casting

This document does not take the place of professional medical advice, however we always advise getting a second opinion if you feel as though your child’s treatment is deviating from the original plan your doctor gave you. Improper casting can compromise treatment. A typical clubfoot can turn into an “atypical/complex” clubfoot with improper casting. Please see our pages regarding red flags and “atypical/complex” clubfoot for more information.




When you get home

Baths

It's incredibly important that you keep the cast clean and dry to prevent chafing and possible infection. We recommend only sponge bathing babies when they are in their casts. Many doctors’ offices will allow you to bath the baby when the cast is removed at the appointment. If water does get in the casts, use a blow dryer on the cool setting and call your doctor.

Clothing

Many use short or long-sleeved onesies. Wide-legged pants, stretchy pants, loose fitting leggings, and elastic waistband pants will work. Leg warmers or a long sock will protect the cast from diaper leakage. Footed pajamas can still work (you may need one size bigger), and regular swaddles will also work. Button-up pajamas are also helpful!

Diapers

Change diapers often to make sure nothing leaks on the cast. You can use a diaper cover over the diaper. Use a wet wipe to clean the cast. The top of the cast should be outside your baby’s diaper.


Breastfeeding

You can still breastfeed your child with little adjustments! Cover the cast with a leg warmer or long sock to keep the cast from irritating you. Using a breastfeeding pillow also helps. If one position doesn’t work, try new ones to get comfortable.

Sleeping

Roll up a towel or small pillow and put under the cast if it is safe for the baby. This will help to support the feet and legs and to make your baby comfortable.

Baby-Wearing

Babywearing can still be done with a clubfoot baby! It is important you make sure the hips are supported. Check out our baby-wearing page for more information.

You can still swaddle in casts and an embe 2 way swaddle is a great choice. You have a legs in or legs out option.




Legs In & Out

Legs Out

When to call the doctor:

  • Cast has an odor and/or there is drainage from cast.
  • Cast is slipping down or has fallen off.
  • If your baby is continuously crying, or has a fever.
  • Has dark and cold toes (blanching of the toes does not occur).
  • If you end up in the ER for cast concerns, it is not recommended that those in the ER re-cast your child. Wait until you can get back to your orthopedic doctor for correct casting.

Difficulties adjusting to casts:

  • To check circulation, press on the toes, they will turn white and then immediately turn to pink again. This is called blanching.
  • If the cast rubs at the top of the thigh, you can use Moleskin and/or a leg warmer or long sock.
  • Ask yourself if your child is uncomfortable or in pain
  • The toes should be visible.
  • Try having baby sleep in a swing, bouncer, Rock and Play, etc.
  • Roll up a blanket or towel and place under the cast.
  • Tylenol or motrin may help (discuss with your doctor before administering any medication to infant/child.)
  • Gas is very common in clubfoot children, so rubbing their tummies or giving them gas drops should help.

Important Reminders

  • Never put anything in the cast.
  • Discuss pain management for your child with the child’s doctor.
  • The cast should not interfere with your child’s scheduled immunizations (most doctors will do injections in the buttocks). If they do in leg above cast, monitor for potential swelling.

Tenotomy

The Achilles tendon, located in the back of the heel, is short and tight in a clubfoot and is resistant to stretching. As a result, approximately 80-90% of clubfoot children require the release of this tendon with a procedure called a percutaneous tenotomy (cutting of the tendon through the skin). This is the final step in the correction process. Most describe this procedure as a poke to the back of the heel, and it takes no more than 10 minutes to complete. The doctor will use a thin scalpel to cut the Achilles tendon. Following the tenotomy, a final cast will be placed on the foot to allow the tendon to grow back in a longer position and will be on for 3 weeks. For most children, the current method of clubfoot treatment does not require them to have surgery beyond a tenotomy. Your child will most likely come home right after this procedure.

Local Anesthesia

Most doctors provide this option. Usually done in the doctor’s office while the child is awake and with either a numbing cream or a shot of pain relief. Discuss oral pain relief when you go home with your doc. Bring the same items you would to a regular casting visit.

General Anesthesia

Some parents prefer that their child is put asleep for this procedure. Your doctor/hospital will provide you with information regarding this process, including scheduling and how soon before the procedure they can eat. Bring the same items you would to a regular casting visit. You can ask the anesthesiologist/doctor what type of anesthesia they will use (gas or needle).

*Ask your doctor for the best way to contact them should you have concerns when you go home from the tenotomy procedure. *A “Z-Lengthening Achilles Tenotomy” is more invasive, not widely used, and not advised.

Post-Tenotomy Cast

The tendon reattaches at proper length in a few weeks while the child is in the post-tenotomy cast. The post-tenotomy cast is applied after and there may be a small amount of bleeding that gets absorbed by the cast. The stain could be a quarter size or larger. This cast stays on for approximately 3 weeks. When this cast is removed, you can expect an overcorrected foot; this is normal and the child should go into the brace stage (boots and bars) immediately to maintain correction. The desired result is 10-20 degrees of dorsiflexion (foot pointing up and 60-70 degrees of abduction (foot pointing out).

PLEASE NOTE: When your child goes in for their tenotomy, make sure you’ve made arrangements to have the boots and bar (brace) ready for when the post-tenotomy cast is removed.




Phase II: Bracing with Boots and Bar

Bracing with Boots & Bar

Congratulations on starting the Boots and Bar (BNB)! Wearing BNB is critical for treatment to be successful. Clubfoot will relapse, or come back, if a foot-abduction brace (FAB) is not implemented. A brace does not correct clubfoot, therefore the feet must be completely corrected before entering this phase. The boots, also referred to as AFOs (ankle-foot orthoses), are only effective when attached to the bar.

Preparing for Boots & Bar

When children begin BNB, they may be fussy. The child may have sore muscles and/or sensitive skin from the casts. They may be uncomfortable and possibly frustrated until they figure out how to move both feet simultaneously. It can take a few weeks to adjust. Discuss with your orthopaedic doctor and/or pediatrician about the use of a pain reliever such as Tylenol. If you suspect there is something wrong, and/or the child is inconsolable, call your doctor immediately.

Recommended schedule for Ponseti Brace Wear

Full Time:

23 hours a day for 3 months.

Weaning:

Slowly weaning to less hours until child is walking.

Part Time:

Nights and naptime, or just nighttime (12-14 hours) until the child is 4 or 5 years old.

Some parents choose to continue part time wear until the child sizes out of the AFO boots.

Tutorials

These tutorials are designed to assist you during the Boots and Bar phase

Tips

Bar Width

The bar width (the distance between the inside edges of the heels of the boots) should be the width of the child’s shoulders. This distance is what is comfortable for the child and prevents knee or hip problems. If you lay the brace on the floor with the boots facing upward, the child’s shoulders should fit snugly in between the boots.





Sizing

Boots should fit in both length and width like shoes. Boots that are too big or too small can cause skin issues. A little room to grow is appropriate, but boots that are too big may cause friction and sores. The toes should meet or extend past the toe strap. The leather straps stretch over time, so tightening the straps as they stretch is necessary.

Placement of the Heel

The heel should be flat against the back of the boot. It may take a few weeks for the heel to “drop” and sit flush in the boot. You should see *most* of the heel through the hole in the back of the boot. Make sure the heel is firmly planted in the bend of the boot, hold in position, and tighten the middle strap first. It's important not to force the heel unnecessarily as this can cause sores.

Degree of External Rotation (Abduction)

The boots should be at an angle of either 60 or 70 degrees for a corrected clubfoot. If the child has an unaffected foot, the boot for that foot should be set to an angle of 30 or 40 degrees.

*If the child has been diagnosed with atypical or complex clubfoot, the boot for the corrected clubfoot should be set to 20 or 30 degrees and worked up to 40 or 50 degrees

Washing Mitchell Boots

  • First, put the boots in a pillow case or mesh laundry sack for added protection.
  • Gentle cycle.
  • Warm water.
  • Little or no soap.
  • Add some towels to the load.
  • Air dry (put in front of fan or in the sun for quicker dry time).
  • Do not wash the bar.

Protecting the Crib or Wall from the Brace

When children are in their brace at night, they may knock their brace on the side of their crib and wake themselves (or you) up. There are a couple things you can do to avoid this and save your crib from boots and bar damage. For older children, we suggest lining the wall with a yoga mat or foam pads.

Crib Alternatives

  • You can put the crib mattress on the floor until the child is in a toddler bed.
  • Use a pack-n-play because it has soft sides.

Boot Covers

  • Put a large sock over the boots
  • Use a large leg warmer over the boots
  • Use large slippers over the boots. There are storefronts online that sell boot covers. Our favorite is: 26th Ave Clubfoot Essentials Website

Sleep Sacks and Pajamas

  • Use a Sleep Sack
  • You can use footed pajamas over the boots if you cut a slit at the bottom for the bar
Please note: to prevent suffocation risks, we do not advise lining the crib with anything.

Preventing a Child from Removing Their Brace

As a child gets older, they may be more likely to remove their boots on their own. Depending on their age, these are some of the ways other clubfoot parents have found effective at keeping the boots on through the night.

  • Using zip ties or twisty ties to tie them on.
  • Sleepsack (forward or backwards).
  • Wrap painter’s tape around the boots.
  • Put a large sock over the boots, make a hole in the heel for the bar.
  • Put boots on opposite feet to make it more difficult for them (Mitchell boots are “straight last” boots meaning there is no curvature, thus, there is no left and right boot).
  • Footed pajamas over the boots, cut a hole for the bar.
  • Coban (stretchy medical tape that sticks to itself).

If the Feet Slip Out of the Boots:

It’s important to ensure the foot is fully corrected prior to starting BNB

  • Criss-cross the top 2 straps.
  • Tighten straps.
  • Try socks with non-slip grip.
  • Put a large sock over the boots, make a hole in the heel for the bar.
  • If the foot continues to slip out of the boot after you've tried these suggestions, call your doctor/orthotist to make sure the feet are indeed fully corrected.



Difficulties Adjusting to Boots and Bar

There is an adjustment period with BNB. Most experience an adjustment period of a few weeks where they are fussier than usual.

  • The skin is sensitive and the muscles are sore after casting.
  • If your child is screaming nonstop and is unable to be soothed, call your doctor immediately.
  • Tylenol or Ibuprofen for the first week or so will help take the edge off while adjusting (discuss with your pediatrician).
  • Try washing the boots to soften the leather (see “How to Wash Boots” section above.)
  • Have baby sleep on an incline or with feet elevated while adjusting.
  • Put BNB on about an hour prior to bed time so child can adjust.
  • Play with your baby while they are in BNB to show them they can move their feet around with the bar on. Making bracing seem like a fun game will help them see it positively.
  • Lots of holding, cuddling, bottle feeding/nursing.

Sores

  • A fully corrected foot, proper fitting boots and appropriate socks will help to prevent foot sores.
  • Red marks are common.
  • Aim to prevent any sore from becoming open and infected.
  • Moleskin, blister band aids, and Duoderm may help too. Bacitracin ointment on an open wound may help.
  • Put baby powder/corn starch in socks to alleviate friction.
  • Pressure Saddles, aka “pringles” is a small piece of silicone that helps to distribute the pressure on the top of the foot that may be created by the middle buckle on the boot (www.mdorthopaedics.com) or sheepskin sewn to the tongue by your orthotist or a local shoe cobbler helps also for preventing sores from the tightness of the middle strap.
  • Ingrown toenails may happen. In the event of an ingrown toenail, let them grow out and keep them a little and cut them straight across. If ingrown toenail becomes infected, call your doctor.
  • Ask your doctor about putting aliplast to the tongue of the boots. This is type of foam pad.

Babywearing Information

Just because your baby has clubfoot, doesn’t mean you cannot babywear! When your little one is in casts as well as boots and bars, you can use any soft structured carrier that supports them ergonomically, as well as woven wraps, stretchy wraps and ring slings. Ensure that their weight is on their bottom versus their knees. Having their legs supported prevents pressure on the hips.

Suggestions: **Try on different carriers before deciding to purchase. You might find the one you really thought you wanted isn’t the best option for you and your little one. If you have a babywearing group near you, you can often try on many carriers before you make a decision. (baby carriers are like jeans: what works for someone else might not necessarily be your favorite or the best fit for you) **Purchase baby legs or put something over the casts when wearing your little one in order to minimize the wear on the carrier.

Examples of carriers that have panels that can be narrowed to accommodate littler babies:

  • Babylonia Flexia
  • Baby Bjorn
  • Baby Bjorn One
  • Beco Gemini
  • Ergo 360
  • Ergo Adapt
  • Infantion Fusion
  • Infantino Flip
  • Lillebaby Complete
  • One Lillebaby
  • Baby Tula Free To Grow

Examples of stretchy wraps:

  • Boba
  • Moby
  • Solly (better for warmer weather) Lillebaby Tie the Knot (better for warmer weather)
  • Wrapsody Hybrid

Red Flags & Atypical/Complex Clubfoot

A to Z Red Flags in the treatment process

Parents/caregivers may want to seek more information or a second opinion for their child if:

  • A) Someone other than a pediatric orthopaedic surgeon is doing the casting.
  • B) The doctor cannot describe his or her training in the Ponseti method.
  • C) The doctor will not say how many clubfoot patients he or she has managed.
  • D) The doctor wants to delay the start of treatment. [Ask the reason(s).]
  • E) Casts slip or fall off.
  • F) Casts are only below the knee.
  • G) Casts are to be worn longer than a week.
  • H) The foot does not improve or looks worse after 2-3 casts.
  • I) The doctor wants you to remove the cast the day before your appointment.
  • J) The doctor recommends Posterior-Medial Release (PMR) surgery.
  • K) The doctor says PMR surgery and the Ponseti method have the same long term results.
  • L) The doctor does not recognize “atypical/complex” clubfoot nor explain how treatment differs.
  • M) The doctor is unsure if a tenotomy is needed. [It is in 80% of cases.]
  • N) A tenotomy is performed before achieving 60-70 degrees of external rotation.
  • O) The cast stays on for more than four weeks after the tenotomy.
  • P) The clubfoot brace is applied before the foot is fully corrected.
  • Q) There is a delay in starting bracing after the last cast is removed.
  • R) The doctor recommends a brace without a bar or just an Ankle-Foot Orthosis (AFO).
  • S) The clubfoot side(s) of the brace is not set at 60-70 degrees of external rotation; the non-clubfoot side is not set at 30-40 degrees.
  • T) The bar is not set to the width of the child’s shoulders.
  • U) The doctor recommends something other than wearing the brace 23 hours for the first 3 months, then nights and naps, and, later, while sleeping until the age of four.
  • V) The doctor or orthotist does not show you how to properly apply the brace.
  • W) The foot continues to slip out of the brace.
  • X) The doctor wants to do Anterior Tibialis Tendon transfer (ATT) surgery before first re-casting to correct a relapse.
  • Y) The doctor wants to do ATT surgery before the child is three years old.
  • Z) Follow-up visits are not scheduled at regular intervals.

Atypical/Complex Clubfoot

A small number of clubfoot cases can be classified as atypical (as seen at birth) or complex (a result of improper casting), and are more difficult to treat. However, they should be able to be corrected without surgery with skilled adjustments and a modified casting technique. With complex cases, you will likely need to see a more skilled doctor for retreatment.

Characteristics:

  • Short, fat, or swollen foot
  • Rigid ankle mobility
  • Short and hyperextended (points up) first toe
  • A transverse (across) crease on the sole of the foot
  • Deep crease above the heel
  • Deep crease in the middle of the sole of the foot
  • Heel area is rigidly tilted inward
  • Foot rigidly flexed downward
  • Heel cord is very tight, wide and long
  • Calf muscle is very small and bunched under the back of the knee.

Improper Casting

  • Casts should not slip down or fall completely off (take a picture of the toes during each casting, then you will be able to determine if the cast has slipped when you’re at home).
  • You should be able to see the toes in the cast.
  • A deep crease on the outside of the foot after casting is indicative of overcorrection and this is not appropriate.
  • Below the knee casts are not appropriate for younger children. Below knee casts do not provide enough force to hold the foot in external rotation. You get more stretching in the medial side leg muscles with above the knee casts.
  • You should not be asked to take your cast off at home before your appointment.
  • The foot should improve from one cast to the next. Each time a new cast is used, the outward rotation of the foot should change by about 10-15 degrees.
  • A pediatric orthopaedic surgeon/podiatrist should be casting the child, not a casting tech or nurse.
  • Rashes, bruising, and skin irritations under the casts should be addresses with the doctor promptly
  • A deep medial crease on the bottom of the foot, which is indicative of “atypical/complex” clubfoot, should improve with serial casting, not become worse.
  • If there was not a deep crease at birth and there appears to be a deep crease after casting, this is indicative of a typical clubfoot becoming complex clubfoot due to improper casting and a second opinion is recommended.




Reference Article

  1. http://www.mdorthopaedics.com/wp-content/uploads/2016/10/complex-proofs.pdf

  2. http://www.journalijar.com/article/ 5518/atypical-clubfoot-:early--identification-and-treatment-by-modification-of-standard-ponseti-technique./


Exercises & Stretching

Although not officially part of the Ponseti method, many doctors recommend physical therapy and exercising as a complementary regimen to bracing. Play (think jumping, running, balancing, etc.) is a great way for older clubfoot kids to get some extra stretching in throughout their day. For stretching babies, please watch the video by Nemours below:

Ramp Stretching

An inexpensive way to stretch the achilles is to use a foam slant from Amazon!

Dorsi Ramp

This ramp can help to encourage a stretch of the Achilles tendons and calf muscles, with 10, 15, and 20 degree slope angles.

Courtesy of St. Louis Children's Hospital Website
Courtesy of St. Louis Children's Hospital Website

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Welcome

BNB

First Cast

12 Hours

Last Cast

Done!